McCullough K, Phelps K, Spinder K, Matava M, Dunn W, Parkers R, MOON Group and Reinke E. Am J Sports Med. Aug 2012; [e-pub ahead of print]. 10.1177/0363546512456836
Anterior cruciate ligament (ACL) injuries are common among young football players. Surgical reconstruction is currently the most common intervention to facilitate return to play, however not all athletes are successful. Unfortunately, there is a lack of data regarding how many football players return to play and what factors may increase the risk of a player not being able to return to play. The purpose of this study was to determine the percentage of high school and college-level football players that returned to play at a minimum of 2 years after an ACL reconstruction (ACLR) and the reasons why players did not return to play. All patients were included in this study from the MOON cohort if they reported football as one of the sports they participated in since surgery or the sport they were playing at the time of their ACL injury. These patients were interviewed regarding their return-to-play status, advancement to the next level of competition, position played, performance after surgery, and (if applicable) reasons for not returning to play. These patients also completed the following validated questionnaires: International Knee Documentation Committee (IKDC), Marx Activity Scale, Knee injury and Osteoarthritis Outcomes Score (KOOS) sports and recreation subscore and quality of life (QoL) subscore. Additional data were gathered regarding concomitant injury (e.g., articular lesions or meniscal involvement) at the time of injury. One hundred forty-seven high school and college-level football players with the potential to continue to play in the following season were included in the final analyses. Sixty-three percent of high school players and 69% of college players returned to play after ACLR. Only 45% and 38% of high school and college players respectively returned to play after surgery at their pre-injury level. Clinically meaningful differences on several of the questionnaires were seen between athletes (high school and college) that had not returned to play and those that had returned to play at their pre-injury level. Of those that had not returned to play after surgery, 50-53% of all athletes reported fear as a contributing factor. Position played was not a predictor for the ability to return to play after surgery. Concomitant injuries were non-significant with respect to return to play after surgery and influence of graft type could not be analyzed due to a wide variety of graft types among the groups.
The percentage of athletes that returned to play after ACLR in this cohort is consistent with previous works [ Ardern 2011, 12m, Ardern 2011,2-7 yr, Ardern 2011, systematic review]. When further evaluating the level of football participation, only 45% of high school athletes and 35% of college athletes were participating in football at their pre-injury level. These percentages are consistent with Ardern 2011 who reported that 45% of athletes were participating in sports at their pre-injury level 2-7 years after surgery. Ardern 2012 reported that athletes that had not returned to their pre-injury level of activity 2-7 years after surgery scored significantly lower on a custom fear questionnaire. Consistent with this current study, fear may be a limiting factor for all athletes that want to return to full athletic competition. This current study confirms and continues to support the evidence that ACLR in athletes does not guarantee full return to play. What does this mean for our athletes? Is there a way to reduce the fear of re-injury and train athletes to minimize their risk of re-injury? What deficits are we not addressing in our post-operative rehabilitation in these athletes?
Written by: Kathleen White
Reviewed by: Jeffrey Driban